Perhaps a more important point than the diagnostic system is the differential diagnosis looking for other causes. There was a paper by Julia Newton reporting that 40% of people referred to the Newcastle clinic received an alternative diagnosis.

Yes, it may be hard to pin down exactly why, but it does look as if there is going to be a big uncertainty problem around the corner. Everything in science rests on probabilities or uncertainties. Sometimes you can minimise these but often only if you make a whole lot of unstated assumptions. With criteria that allow the assessor to choose from about fifty symptom options, all of which are subjective, I think uncertainty is bound to be an issue. Anything objective, however low on specificity or sensitivity, would help.

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Its not just the matching of a set of symptoms but also the filtering of other diseases where care needs to be taken. The uncertainty around entry conditions makes me worry about small trials. For example if you have 10 patients but 4 of them have other problems such as a sleep disorder then 2/3rd sucess on the others would only leave 4 out of 10 giving a response with a probability of less.

I guess this is the importance of having a good initial diagnostic process as part of a trial. Many trials seem to use mild and moderately affected patients as its easier. Do you have a preference? - I would have thought more severe patients would have easier to measure improvements and perhaps easier to see changes in any blood results.

Here is a short (lay) explanation of the above PANDAS research (from an article on this forum), which perhaps you may find interesting, if you haven't come across it already...

PANDAS [...] believed to be autoimmune disorders, triggered by bacteria, that lead to neuropsychiatric symptoms - and they occur almost exclusively in children. PANDAS are characterised by OCD, anxiety and even tics, where the symptoms come on very suddenly after a streptococcus infection (usually strep throat or Scarlet Fever). The underlying biology seemed to be that strep bacteria trigger 'autoantibodies', antibodies that attack strep but also happen to attack human cells, particularly in the basal ganglia in the brain. It's not clear how the antibodies cross the blood-brain barrier, but that's likely to be an important factor in explaining why most strep infections don't cause PANDAS.

From children to mice

Hornig's team used a mouse model to study the illness in more detail. They infected mice with the same bacteria that cause strep throat and found obsessive-compulsive behaviour similar to that seen in humans (for mice it includes repeated back-flipping). Crucially, they were able to show that mice produced antibodies against strep in the blood, but that these antibodies also bound to brain proteins. What's more, they found deposits in the brains of PANDAS mice, and the presence of these deposits was linked to PANDAS symptoms.

[image]

Next, they did something very clever. They were able to reproduce the PANDAS syndrome - back-flips and all - in healthy mice that had been injected with serum from PANDAS mice - no Strep involved. (Serum is the part of the blood that contains antibodies). Critically, they found deposits in the brains of these previously-healthy mice, indicating that antibodies from the serum had attacked the brain of the healthy mice, leading to the PANDAS symptoms. To make sure it was really the antibodies in the serum doing the damage, they selectively removed antibodies from the serum - and it could no longer induce PANDAS in healthy mice. (more detail)

[image]

From mice back to children

Then they were able to identify the proteins in mouse brains that were being targeted by the autoantibodies linked with PANDAS. The proteins included two that are produced in response to stress (one is snappily called HSP-70). The team now returned to the children with PANDAS and looked at those children's sera - and found the children's sera (and antibodies) bound to the same protein, HSP-70, that was attacked in mice.

So Mady Hornig and her colleagues, including Ian Lipkin, started off with a human illness triggered by strep bacteria, then looked at that illness in detail in a mouse model, showing the key role of autoantibodies in the disease. And they found a likely target protein in the mouse brain for these antibodies. Finally, they completed the cycle by showing that children with PANDAS have sera that attacks the human version of the protein involved in mice. That is neat.

Prof Mady Hornig is also currently working on a huge and expensive (multi-million-dollar) ME/CFS investigation with Prof Ian Lipkin, looking for any pathogens, proteins, DNA etc. that might be associated with ME/CFS. (Using a range of tissue types.)

The latest verypreliminary news is that the Lipkin/Hornig team say they may have found a 'possible' candidate in terms of finding something (protein, pathogen, DNA?) associated with ME.

It's just a thought, but perhaps it would be worth contacting Mady Hornig, to see if she has any thoughts about potential biomarkers, that could be useful for your study?

It's probably too early for her to share any info with you, but I just thought I'd mention it, in case helpful.

Its not just the matching of a set of symptoms but also the filtering of other diseases where care needs to be taken. The uncertainty around entry conditions makes me worry about small trials. For example if you have 10 patients but 4 of them have other problems such as a sleep disorder then 2/3rd sucess on the others would only leave 4 out of 10 giving a response with a probability of less.

I guess this is the importance of having a good initial diagnostic process as part of a trial. Many trials seem to use mild and moderately affected patients as its easier. Do you have a preference? - I would have thought more severe patients would have easier to measure improvements and perhaps easier to see changes in any blood results.

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I think having a trial that includes both mild/moderate and severe patients is important. A greater severity may not necessarily mean more pronounced bloodwork. It would however be easier to objectively measure a symptom improvement in these patients.

The trouble with a smaller study is that it puts more importance on the patient selection, The initial diagnostics will be important to rule out other illnesses but I don't doubt that this will be done to a high standard due to the experience of the group who will be carrying out the trial. After that, it is important to get a slightly wider range of diagnosed ME patients; with differing severity and symptoms groups. The most important thing for me has to be the preliminary work looking at B-cells and identifying whether any problems here correlate to patients who improve on the drug.

With criteria that allow the assessor to choose from about fifty symptom options, all of which are subjective, I think uncertainty is bound to be an issue. Anything objective, however low on specificity or sensitivity, would help.

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You may be aware that the ICC requires PENE which is operationalized this way in the ME Primer:

Dr. Peterson uses biomarkers for entrance and outcome criteria, but using VO2 max as an outcome measure seems to be causing him a storyline problem anyway. His research assistant, Gunnar Gottschalk, says, “We'd like to investigate the mechanism of the increase in VO2 max as well, post and during Cidofovir treatment, and we'd like to do this in a multi-centre fashion (Recording 5, at 9:10 – 9:20).” Dr. Peterson notes:

I am intrigued by why an antiviral improves NK cell function. You can look at it simplistically, Nancy, that you decrease the viral load and the work of the NK cell, but I'm not sure it's that simple, and that's why we're trying to figure out a mechanism of that, as well as the VO2 max. Why should an antiviral improve VO2 max? By standard pathophysiology, it shouldn't. My personal belief is that these tricky viruses are messing with the mojo of the mitochondria through a cytokine mechanism, and that when you decrease the viral load, things change (18:50 – 19:35).

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In his CPET Presentation Part II, Dr. Snell seems to be alluding to additional data that flows from the Stevens Protocol indicating subgroups:

We get an objective measurement of impairment which then we can equate to disability. We also have a mass of information that can be used diagnostically.... There are published papers on how you isolate or identify what energy systems appear to be compromised to explain the results of a cardiopulmonary exercise test (0 – 0:40). [...]

So, a variety of things that we can rule out. If we don't rule out those things, then we're left with certain systems. A couple of possible explanations for these fatiguing conditions are related to immune function, which is a system that cuts across multiple other systems, and the autonomic system, the system that controls everything. And certainly for ME, you can come up with an autonomic subgroup or an immune subgroup.

So we're starting to narrow down the illness a little bit, and we're starting to get certain things that people might then start to look at in the laboratories. They might start to develop treatments to treat symptoms, or we really hope one day that somebody will come up with a cure. So what's causing all of these problems way down the line, lowest common denominator. Let's see if we can fix that. So once again this is all legitimate science, well-established and well-accepted in the medical community (12:20 – 13:35).

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The ME Primer suggests using similar prominent-cluster subgroups, i.e., neurological, immune, metabolism/cardiorespiratory or eclectic (balanced). These are detailed in its Systems Review, Physical Examination and particularly in its Laboratory/Investigative Protocol:

Laboratory/Investigative Protocol: Diagnose by criteria. Confirm by laboratory and other investigations.A broad panel of tests provides a more robust basis to identify symptom patterns, abnormalities and orient treatment. ​

Further testing with specificity to ME,if and as indicated. Some tests are in the research stage but can identify abnormalities and focus treatment. Viral tests should be interpreted by a physician experienced in these infections. ​

Dr. Broderick has yet to introduce the International Consensus Symptom Scale (ICSS). In Cort Johnson's interview two years ago, Marj van de Sande imagined a future when “the practice of comparing research results with prominent symptom clusters of the patients as indicated in their ICSS brought mutual confirmation and better treatment strategies.”​

Then they were able to identify the proteins in mouse brains that were being targeted by the autoantibodies linked with PANDAS. The proteins included two that are produced in response to stress (one is snappily called HSP-70). The team now returned to the children with PANDAS and looked at those children's sera - and found the children's sera (and antibodies) bound to the same protein, HSP-70, that was attacked in mice.

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Rather intriguing that three studies have found impaired HSP response to exercise stress in ME/CFS :

The findings of heat shock proteins at the site of neural ‘aggregations’ in neurodegenerative diseases such as Alzheimer’s, Parkinson’s and Huntington’s disease might suggest they provide a protective response against neurodegeneration (Peter Csermely and Ichiro Yahara, 2003) and may protect the brain against glutamate induced excitotoxicity.

The uncertainty around entry conditions makes me worry about small trials. For example if you have 10 patients but 4 of them have other problems such as a sleep disorder then 2/3rd sucess on the others would only leave 4 out of 10 giving a response with a probability of less.

I guess this is the importance of having a good initial diagnostic process as part of a trial. Many trials seem to use mild and moderately affected patients as its easier. Do you have a preference? - I would have thought more severe patients would have easier to measure improvements and perhaps easier to see changes in any blood results.

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I continue to be intrigued by how many people want a big trial. If we think only 4 out of 10 will respond in a small trial, we have exactly the same problem for a large trial. We are not looking just for any responses but the proportion of responses, which should be the same - 40%. That immediately implies that the bigger the trial the more people will be given an inappropriate, and potentially risky, treatment. That makes it is essential that we do the smallest trial we can. With a bigger trial the statistical significance should improve for the same percentage response but there is a major problem with large trials - lots of people are diagnosing and assessing and that makes for much greater uncertainty about reliability. In my experience, response rates in large trials go down very considerably.

I am generally in favour of treating severe cases in trials, on the basis that there is more to respond. However, there are several reasons why very severe cases may show poor responses, as I have mentioned before. In most rheumatic diseases we try to distinguish severity from 'activity', the latter being something we think is reversible. For ME that may be difficult.

Dr. Peterson uses biomarkers for entrance and outcome criteria, but using VO2 max as an outcome measure seems to be causing him a storyline problem anyway. His research assistant, Gunnar Gottschalk, says, “We'd like to investigate the mechanism of the increase in VO2 max as well, post and during Cidofovir treatment, and we'd like to do this in a multi-centre fashion (Recording 5, at 9:10 – 9:20).” Dr. Peterson notes:
In his CPET Presentation Part II, Dr. Snell seems to be alluding to additional data that flows from the Stevens Protocol indicating subgroups:

The ME Primer suggests using similar prominent-cluster subgroups, i.e., neurological, immune, metabolism/cardiorespiratory or eclectic (balanced). These are detailed in its Systems Review, Physical Examination and particularly in its Laboratory/Investigative Protocol:

Dr. Broderick has yet to introduce the International Consensus Symptom Scale (ICSS). In Cort Johnson's interview two years ago, Marj van de Sande imagined a future when “the practice of comparing research results with prominent symptom clusters of the patients as indicated in their ICSS brought mutual confirmation and better treatment strategies.”​

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One difficulty I see is that we do not have any particular reason to think that biomarkers of things like muscle metabolism will be useful for predicting a response to a B cell treatment. In a strange sense we are not looking for better 'markers of ME' but for better markers of illness that responds to rituximab, which is why I think that has to be something relevant to B cells. To my mind, at present, we have to stick as closely as possible to the way Drs Fluge and Mella selected patients, because that is the group we think responds quite well, and study B cell related ways of sharpening that up. We want to do that on as small a group as we think will give us an answer that gets us one step sharper. Then we can try for two steps.

Thanks Bob. Yes I was aware of this approach. I heard Dr Hornig speak in London in May. I won't give a detailed analysis because much of what I might say has come up in previous discussion. One point I think may be worth making is that the self antigens they mention - C4, alpha2 macroglobulin and HSP-70 are not brain proteins. They are everywhere in the body and they are immunoregulatory proteins. Exactly how production of antibodies to these proteins comes about is I think still a very difficult call, as is the reason why the basal ganglia suffer after streptococci, along with skin, joints and kidneys in other post-streptococcal variants. The antibodies associated with RA, called rheumatoid factors, which are anti-antibody antibodies, also occur after acute bacterial infections but they do not persist. But these issues aside, I think the model provides another good example of just how many ways there might be to produce an illness like ME through B cell misbehaviour and so is good grist to the mill. All these approaches show just how plausible an immunological model for ME is.

Today's announcement from IiME contained some - I think - additional data that appears to imply you will be seeking to replicate Bansal's work:

The first part of the trial will be a preliminary study which will be designed to confirm and extend the earlier work of Dr Amolak Bansal [1] on B-cells but using a different cohort of ME patients.

Professor Edwards believes this is a useful study in its own right and a pre-requisite for the clinical trial.

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Are you in a position to explain, a) if Bansal's findings are enough to pre-determine suitability for treatment with Rituximab; b) if indeed 'confirm' (in the above) equates to a replication effort and what the implications of non-replication might mean; and c) what 'extend' (in the above) might also mean?

If a replication is what we are talking about, then what kind of size would be deemed suitable in terms of patients and controls; and is there any idea of a time-frame to get this done (presumably before embarking on any major Trial attempt)? I guess cost is not something that can be estimated at this point; but preliminary work - as we have been discussing - seems to be vital here.

Bansal's study was well received, I'd just like to know if it is enough, and if not, then what else might you need. I appreciate you may not be in a position to go into detail about something you are still working on with UCL; but I'd like to better understand the significance and relevance of Bansal's work if you are able to help, as I have only been able to read the extract:

Chronic fatigue syndrome (CFS) is a heterogeneous disorder of unknown aetiology characterized by disabling fatigue, headaches, sleep disturbance and several other symptoms.

The onset of CFS may follow a viral infection or period of stress. Patients with CFS do not have hypogammaglobulinaemia, predisposition to recurrent bacterial infections or symptoms of autoimmunity.

To date, defects in B cell numbers or function have not been shown in the literature. However, treatment with anti-B cell therapy using Rituximab has recently shown benefit to CFS patients.

We therefore postulated that patients with CFS had a subtle humoral immune dysfunction, and performed extended B cell immunophenotyping.

We undertook a detailed characterization of the proportions of the different B cell subsets in 33 patients with CFS fulfilling the Canadian and Fukada criteria for CFS and compared these with 24 age- and gender-matched healthy controls (HC).

The Mignot review is very helpful. It seems that there are other susceptibility genes related to T cell function so this confirms that immune signalling is almost certainly involved. The DR1 association pointed to that but for years nobody could quite believe the implications. Also the occurrence of narcolepsy in children after flu jabs looks very hard data. The time course of development over a year but not more is also very interesting. That could be the time course of a short lived plasma cell response. There is also the fact that most people with DR1 do not get narcolepsy so there is still a random factor involved. Finally, he admits that no autoantibodies or T cell responses to hypocretin have been found. That to me confirms the suspicion that molecular mimicry is too simple a theory. Something more subtle is going on, just as coeliac is a bit more subtle.

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Phew - I am finally up to date with this thread again! Brain fog, eye fatigue and work have been getting in the way.

Could not the fact that most people with DR1 do not get narcolepsy indicate a possible environmental trigger?

T One point I think may be worth making is that the self antigens they mention - C4, alpha2 macroglobulin and HSP-70 are not brain proteins. They are everywhere in the body and they are immunoregulatory proteins.

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I'm not sure I'm following this line of argument. If HSP's are not brain proteins they do appear to play an active role?

A remarkable intrinsic resistance of brain to hyperthermia reflects protection mediated by constitutive and induced expression of HSPs in both neurons and glia.

To my mind, at present, we have to stick as closely as possible to the way Drs Fluge and Mella selected patients, because that is the group we think responds quite well, and study B cell related ways of sharpening that up. We want to do that on as small a group as we think will give us an answer that gets us one step sharper. Then we can try for two steps.

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Thanks! As Dr. Broderick observes on behalf of the International Consensus Panel, “One only has to question why 5 of 15 CFS patients in recent phase II clinical trials of rituximab were unresponsive to treatment to appreciate the need for more specific criteria.”

Phew - I am finally up to date with this thread again! Brain fog, eye fatigue and work have been getting in the way.

Could not the fact that most people with DR1 do not get narcolepsy indicate a possible environmental trigger?

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The presumption is that in the flu vaccine study the environmental trigger is the flu jab. Yet only one in 10,000 people getting the jab showed signs of narcolepsy afterwards. You could say that they had some other coincident trigger but I see no need to invoke another environmental trigger when we have a random mechanism for antibody generation. Consider the analogy to cancer. Exposure to cosmic rays increases the risk of cancer very slightly. The difference between those who get cancer and those who do not is a random mutation in DNA due to the irradiation that just happens by chance to muck up a growth regulator gene or some such. All antibodies are made by a strange mechanism that goes around punching holes in antibody DNA and sewing them up differently - at random. Everybody is happy with randomness in cancer. I think it is worth thinking about it here too.

Today's announcement from IiME contained some - I think - additional data that appears to imply you will be seeking to replicate Bansal's work: Are you in a position to explain, a) if Bansal's findings are enough to pre-determine suitability for treatment with Rituximab; b) if indeed 'confirm' (in the above) equates to a replication effort and what the implications of non-replication might mean; and c) what 'extend' (in the above) might also mean?

If a replication is what we are talking about, then what kind of size would be deemed suitable in terms of patients and controls; and is there any idea of a time-frame to get this done (presumably before embarking on any major Trial attempt)? I guess cost is not something that can be estimated at this point; but preliminary work - as we have been discussing - seems to be vital here.

Bansal's study was well received, I'd just like to know if it is enough, and if not, then what else might you need. I appreciate you may not be in a position to go into detail about something you are still working on with UCL; but I'd like to better understand the significance and relevance of Bansal's work if you are able to help, as I have only been able to read the extract:

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I think it would be difficult to say much more just yet. Dr Bansal's data do not tell us who should have rituximab but we can work towards finding out whether his approach could do that. Technology improves all the time so I hope UCL can not only repeat his study, but go into more detail. The logistics are fairly straightforward. What I think is so encouraging is that less than two months after meeting up with IiME, all the necessary resources for getting this project started, including people, facilities, expertise and finance, look to be in place. Online communication, including on PR I guess, has played a major part in getting things to that point. I have to say that trying to get research up and running in this style is a bit new for me but if it works so well, I am all for it. It seems to be a remarkable example of 'patient power' driving the agenda and that must be a good thing.

HSPs are present in all cells as far as I know. The puzzle then is why antibodies to HSP-70 (which have also been reported in rheumatoid arthritis patients who have no brain problems) should be associated with a problem in one specific part of the brain. It is a particular puzzle because antibodies do not normally even get in to the brain because of the blood brain barrier. It would seem that maybe something else has affected that part of the brain to make the blood brain barrier leaky there. That raises the question whether this something else is actually all we need to explain the brain problem anyway. These are some of the almost endless tricky questions that beset our models of autoimmunity. We can never quite be sure what does what.

Online communication, including on PR I guess, has played a major part in getting things to that point.

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I don't know that we in particular can claim much of the glory for that since it's very much a broad effort but I'd certainly say that the internet, and the growth of any number of online ME communities and networks must surely have extended the wider ME community's reach considerably in recent years in terms of fundraising. With a worthwhile project like this, we can all work together and get the word out to potential donors - the many small ones and the fewer big ones - very quickly.

I continue to be intrigued by how many people want a big trial. If we think only 4 out of 10 will respond in a small trial, we have exactly the same problem for a large trial. We are not looking just for any responses but the proportion of responses, which should be the same - 40%. That immediately implies that the bigger the trial the more people will be given an inappropriate, and potentially risky, treatment. That makes it is essential that we do the smallest trial we can. With a bigger trial the statistical significance should improve for the same percentage response but there is a major problem with large trials - lots of people are diagnosing and assessing and that makes for much greater uncertainty about reliability. In my experience, response rates in large trials go down very considerably.

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By all means keep on being intrigued. An interesting read of the history of our disease, told from the US, is Osler's Web, from Hillary Johnson.

It tell about decades of being ignored, being told it's in our head, being denied insurance benefits, being robbed of a life, getting married, having children and decades of being humiliated by physicians, especially in the UK.

To this day we are being told that CBT and GET are the best treatments and this is what you should do whether you are too ill to feed yourself or you are 80% bedbound.

Meanwhile patients keep on taking their own lives because there is no hope for them and nothing to look forward to when all that they could has been tried.

You cannot imagine how rough living with this disease is, when family members think you are lazy, your employer thinks you are malingering and faking an illness in order to get benefits and your doctor doesn't believe what you say and when your country is denying research funding, turn around and grant millions if not billions in research for cancer and HIV AIDS.

So you are asking me if I am willing to donate cerebro-spinal fluid, bonne marrow sample, muscle sample, blood, other fluids and if I will submit to a 2 ocnsecutive days VO2 max test, and agree to be a participant into a drug trial, may it be double blind, randomized or phase 1, never tested on humans, I will say to you, "Hell ya!"

P.S. re-reading your first sentence, it sounds like you are surprised as of why pts want a BIG trial... Some of the above applies but I would argue that bigger sample provide more convincing results, no?

P.S. #2 By all mean I am thankful for Dr Edwards's involvement and it is my hope that his efforts will be rewarded. I am also very thankful that he is sharing thoughts, knowledge and opinions over here.

I ..... I have to say that trying to get research up and running in this style is a bit new for me but if it works so well, I am all for it. It seems to be a remarkable example of 'patient power' driving the agenda and that must be a good thing.

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that might be also phrased ."patient financing"?... a little quicker turnaround than government grants, eh?

Prof. Edwards, I'm curious if someone is going to do very detailed patient histories?